Coding Chapter 11 – Flashcards
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What is the surgery section?
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The largest section of CPT which contains codes and code descriptions for surgical procedures performed by physicians
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Why does the surgery section contain multiple codes that describe similar procedures?
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Because procedures can be performed in a variety of methods and different combinations
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What guides the physician to do one or multiple procedures?
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The patient's physical status
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What guides the selection of the appropriate code for reimbursement?
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The documented op report and other patient documentation
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Overview of Surgery Section
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...
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The subsections in the surgery section are organized _________.
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Anatomically
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Anatomically
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body area or organ system
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Categories and subcategories are organized within subsections according to _____________.
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type of procedure
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What does selection of the appropriate surgery code require?
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careful review of the patient record to determine the procedure and services provided
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What should you do before looking in the index for the appropriate code?
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review the op report to determine the body system, site, surgical approach, and type of procedure performed, and if multiple procedures were performed
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Example: Excision of cervical stump
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was it performed through the abdominal approach or the vaginal approach?
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Example: Removal of malignant lesion
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was it performed via excision or destruction?
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What does CPT coding descriptions include
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the procedure performed
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CPT coding descriptions do NOT include
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numerous activities integral to the procedure
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True or False: It would be impractical to list every event common to all procedures of similar nature in the codes narrative description.
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True
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True or False: Many common activities represent the principles of the medical and surgical care but are not coded separately.
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True
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True or False: Some activities are only integral to certain groups of procedures.
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True
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List some standard services that are integral to the med/surgical section:
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-Cleaning, shaving, and prepping -Draping and positioning -Inserting intravenous access for medicines -Administering sedatives -Administering local, topical, regional anesthesia -Est. the surgical approach -Performing lysis on simple adhesions -Isolating neurovascular ,muscular, or bony structures that limit access to surgical field -taking surgical cultures -irrigating wounds -inserting or removing drains, suction devices, dressings, and pumps -closing the surgical incision -applying, managing, and removing postop dressings including analgesic devices -documenting reports -identifying surgical supplies
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Organization of Surgery Section
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...
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The guidelines located at the beginning of the surgery section apply to ________
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all codes in the section
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Notes located throughout the surgery section apply to _________
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a specific subsection, heading, or subheading based on type and site of procedure
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What subsections are included in the Surgery Section?
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-General -Integumentary -Musculoskeletal -Respiratory -Cardiovascular -Hemic and Lymphatic -Mediastinum and Diaphragm -Digestive -Urinary -Male Genital -Female Genital -Reproductive -Intersex -Endocrine -Nervous -Eye and Ocular Adnexa -Auditory -Operating Microscope
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Incision
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cut made into body tissue during surgery using a knife, electrosurical unit, or a laser
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I & D
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Cutting open a lesion and draining its contents
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Excision
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Removing a portion or all of an organ or another tissue using a scalpel or another surgical instrument
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Introduction
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Injecting, inserting, or puncturing body tissue or scoping an organ
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Removal
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Eliminating tissue or taking something out
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Endoscopy
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Visualizing a body cavity using an instrument that can be inserted into the body through a small incision or a natural opening
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Endoscope is also used as a ______
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Surgical approach for performing other procedures
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Repair
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Improving improperly functioning body parts
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2 Types of Repairs
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grafts and sutures
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Grafts
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moving healthy tissue from one site to another to replace diseased or defective tissue
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Suture
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Closing a wound using catgut, glue, silk thread, wire, or other materials
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Revision
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Modifying a previous procedure
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Reconstruction
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Rebuilding a body part, such as the breast
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Destruction
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ablation or removal of benign, pre-malignant, or malignant tissue
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Types of destruction
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-chemo-surgery -cryosurgery -electrosurgery -LASER -Surgical curettment
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Chemosurgery
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Using chemicals to destroy diseased tissue, such as for skin cancer
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Cryosurgery
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Applying extreme cold, such as liquid nitrogen, to destroy abnormal tissue cells, such as warts or small lesions
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Electrosurgery
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Using an electrical device, such as electrocautery , to destroy abnoral tissue
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LASER stands for
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light amplification by stimulated emission of radiation
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LASER
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using a device that if filled with a gas, liquid, or solid substance that is stimulated to emit light to a specific wavelength to burn, cut, or dissolve tissue.
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Other procedures
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Unrelated procedures, which include arthrodesis, Mohs micrographic surgery, manipulation, splinting, or casting
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How are procedures categorized in the surgery section?
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therapeutic or diagnostic
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Diagnostic procedures
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performed to evaluate the patients complaints or symptoms to establish the dx (biopsy, arthroscopy, endoscopy)
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Therapeutic Surgical Procedure
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performed to treat specific conditions or injuries which includes the procedure itself and normal uncomplicated follow up care (repair or removal)
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Terms like incision, repair, removal, revision, etc are all types of __________
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subheadings in the surgery section
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Surgery Guidelines
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What do guidelines located at the beginning of the CPT surgery section do?
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ckarify the assignment of codes and explain terms
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Surgery Guidelines include:
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-Services -CPT surgical package definition -Follow up care for diagnostic procedures -Follow up care for therapeutic procedures -Supplied material -Reporting more than 1 procedure/service -Separate procedures -Subsection information -Unlisted service or procedure -Special report -Surgical destruction
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Services
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What is located in the E/M section of CPT?
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codes for physician services that are provided in the office, patient's home, hospital, and other health care facilities and codes for consults and other medical services
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Where are codes for special services and reports located?
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in the CPT Medicine Section
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CPT Surgical Package Definition
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Services included in the CPT surgical package are
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-local infiltration. metacarpal/tarsal, or topical -One related E/M service following the decision for surgery -Immediate postoperative care -Documentation of Postop physician orders -Evaluation of the patient in the post anesthesia recovery area -Typical postop follow up care
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What does immediate postoperative care include?
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dictating the operative report and taking with the family and other physicians or qualified health care professionals
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What does decision for surgery include?
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history and physical on the date of surgery or immediately prior to performance of surgery
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What did CMS do in 1992?
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Established a national global definition for global surgical package that differs from CPT's surgical package definition
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Why did CMS come up with a definition of global surgical package?
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to make sure payments are made consistently for the same services across Medicare administrative contractor jurisdictions
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The Global Surgical Package definition prevents
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Medicare payments for services that are more or less comprehensive than intended
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What does the CMS global surgical package include?
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the surgical procedure and a standard package if preoperative , intraoperative, and postoperative services
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CMS categorizes surgeries as ____ or_____
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major or minor
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CMS established a postoperative ______ period
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global (0, 10, or 90 days)
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The global period for major surgeries is _____
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90 days
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The global period begins the day _____ surgery
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following
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The global period includes a ____ preoperative period
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one day
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When reporting a CPT surgery code, ______ are included in that code and not separately coded
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surgical package services
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To determine the global period for major surgeries:
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count the day before the day of surgery, the day of surgery, and the 90 immediately following the day of surgery (Examples pg. 506)
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To determine the zero-day global period for minor surgeries:
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count the day of surgery only (Examples pg. 506)
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To determine the 10-day global period:
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count the day of surgery and the appropriate number of days immediately following (Examples pg.506)
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Where does CMS publish a list of the global periods for each CPT code?
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The Federal Registar (also includes some alphabetical codes in the global period)
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MMM
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Global period policy does not apply; describes services furnished in uncomplicated maternity cases, including antepartum care, delivery, and postpartum care
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XXX
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Global period policy does not apply
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YYY
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Global period established by each MAC
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ZZZ
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COT code is related to another service provided, which is always included in the global period of the other service
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What do instructions for the global surgical package describe?
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the components of a global surgical package and payment rules for minor surgeries, endoscopies, and global surgical packages that are split between physicians
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What items does the CMS global surgical package include?
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-Preoperative services -The day before surgery -The day of surgery -Intraoperative services -TX of complications -Postoperative visits -Post surgical pain management -Miscellaneous services
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What does the CMS global surgical package NOT include?
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-Initial consult or evaluation services -Visits unrelated -Services provided by other physicians except when physicians agree on transfers -DX tests and procedures -clearly distinct surgical procedures -tx for postoperative complications that require a return trip to operating room -a requires more extensive procedure when a less extensive fails
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The procedure being performed determines the ____
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global follow up care (NOT the condition being treated)
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The global surgical package deals with the procedures performed during the global period by the _______
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operating surgeon only
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True or False: E/M services provided as follow up to a surgical procedure are included in the reimbursement amount for the surgery , and codes for the follow up E/M services are not reported separately..
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True
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When the patient receives the E/M service for an unrelated condition, make sure you report an ____ to receive reimbursement
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E/M code
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When an E/M service provided is for the purpose of deciding surgery, the E/M code is considered a significant _____ service
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Separately identifiable
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MACs use software that contains _____ to detect the separate billing of services included in the global package
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prepayment edits
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What happens when an E/M code is provided for services provided during a global period and a modifier is not used?
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Claim is denied
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Local Infiltration, Metacarpal/Metatarsal/Digital Block, or Topical Anesthesia
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...
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True or False: Local infiltration, metacarpal/metatarsal/digital block, or topical anesthesia, when provided by the physician performing the procedure, is considered part of the procedure.
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True (when provided by the surgeon, add modifier -47)
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When a physician other then the surgeon provides general anesthesia, regional anesthesia, or monitored anesthesia care, the other physician reports an _______ code for services provided
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anesthesia
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Moderate (conscious) Sedation
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moderate sedation or analgesia that results in a drug-induced depression of consciousness
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True of False: CPT established a package concept for conscious sedation and a bulls eye located next to the code number identifies the conscious sedation as an inherent part of providing specific procedures.
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True (it would be inappropriate to report both the procedure and a separate conscious sedation code)
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True or False: The management of postoperative pain by the surgeon, including epidural drug administration, is included in the global package with the operative procedure.
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True
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Follow-up Care for Therapeutic Surgical Procedures
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__________ are performed to evaluate a patient's condition, to determine the nature of the condition, and to distinguish between one disease and another
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Diagnostic Procedures
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What does CPT say follow up care for dx procedures includes?
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only that care directly related to recovery from the diagnostic procedure itself
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Which codes should be provided for follow up care for dx procedures?
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- the patient's condition for which the dx procedure was performed -other conditions that are not related to the reason for performing the dx procedure
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True or False: When a patient receives services from the physician who performed the diagnostic procedure and those services are in follow up to the procedure performed, do not report a code for services provided.
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True
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Follow up Care for Therapeutic Surgical Procedures
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________are performed for the definitive treatment of a disease or condition rather than for dx or investigational purposes
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Therapeutic
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What does follow up care for therapeutic procedures include?
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only the care that is typically considered part of the surgical service
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True or False: The physician generally sees the patient several times as part of normal, uncomplicated follow up care.
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True (included in global package)
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True or False: Normal follow up care is a necessary component of the surgical process.
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True
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When should codes be provided during therapeutic follow up care?
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-complications -exacerbation -recurrence -presence of other diseases -injuries
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Supplied Materials
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Supplies commonly included in the surgical package are not _____
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coded separately
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Only those supplies and materials provided by the physician over and above the supplies usually included with the procedure rendered are _____
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coded separately
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True or False: The CPT surgery section does not identify procedure codes for which it is inappropriate to report supply items separately.
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True
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__________ is a specific reimbursement issue which varies from one payer to another.
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Reimbursement of supplies and materials required to perform the procedure
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True or False: CMS created specific instructions regarding the separate reporting of supply items
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True
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What happened with the full implementation of the practice expense component of the Medicare Fee Schedule?
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all supplies are now included in the payment for the procedure, Medicare no longer reimburse the physician for this code (some non Medicare payers will allow this though or the code for supplies above and beyond the usual)
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Reporting More than One Procedure/Service
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What applies when a physician performs one or more procedure or service on the same date, during the same op session, or during a postop period?
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The surgical package concept of reporting one or more CPT modifiers to receive reimbursement consideration from third party payers
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Add-On Codes
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Plus sign
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next to add on codes that describe a service that can be reported only in addition to a primary procedure
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How else may an add on code be identified other than a plus sign?
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By specific language in the code description such as each additional or list separately in addition to
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True or False: Add on codes are never stand alone
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True (they are integral part of another procedure and would not be performed without the primary procedure)
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______ allow physicians to separately report procedures and services performed in addition to the primary procedure
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Add on codes
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What is the key to identifying add on codes?
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Determining whether the code always has to be reported with another code
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Add on codes are exempt from the
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multiple procedures concept (-51)
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Separate Procedure
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CPT codes that contain the term separate procedure in parenthesis are commonly performed as an _____ component of a total service
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integral
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When the total procedure or service is performed, do not report ad an additional procedure the code that contains the term ________in its code description
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separate procedure
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When a separate procedure is performed during the same op session as a more comprehensive procedure,____________
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do not code the separate procedure in addition to the more comprehensive procedure
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What do you do when a service that contains the separate procedure in its code description is performed distinctly?
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report the separate procedure code in addition to codes for other procedures (or services)
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Reporting separate procedures may be necessary to classify:
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-Procedure performed during a different session, surgery, site, or organ system -Procedure performed through a separate incision or excision -Separate lesion excised during the same operative session as removal of another lesion -Tx of separate injury
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Add modifier ___ to the separate procedure code to indicate that the procedure is not considered a component of another procedure but is distinct
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-59
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Subsection Information
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Many of the surgery subsections contain unique instructions called
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notes
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Where are notes located?
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Just below the title of the subsection
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Where are parenthetical notes located?
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below codes (they apply to just that code)
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Unlisted Service or Procedure
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When are CPT unlisted procedure codes assigned?
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when no specific code accurately describes the procedure performed
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What must you include when reporting an unlisted procedure code on an insurance claim?
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written report that describes the procedure performed
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Special Report
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Special report describes
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the procedure performed in an unlisted code submission
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Special reports may be required for procedures and services _____ provided or they are _______
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rarely provided or unusual
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Special reports establish ________
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medical necessity
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As a minimum, to document a special report, include the following:
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-adequate description of the nature, extent, and need -time, effort, and equipment necessary to provide the procedure or service -complexity of symptoms -concurrent problems -dx and therapeutic procedures -final diagnosis -follow up care -pertinent physical findings
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Surgical Destruction
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Surgical destruction is considered part of a __________procedure
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surgical
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Different methods of destruction are not reported separately unless
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the technique substantially differs from the standard management of a problem or condition (CPT codes are available for exceptions due to special circumstances)
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Surgical destruction
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the ablation (or removal) of tissues by any method, including chemical tx, cryosurgery, electrosurgery, or laser
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General Subsection
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How many codes does the general subsection have?
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Just 2 -10021 (fine needle aspiration without imaging) -10022 (fine needle aspiration with imaging)
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FNA
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Fine needle aspiration
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Fine needle aspiration defined
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the removal of fluid from a cyst or cells from a solid mass to be examined cytologically
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FNA is a ___________ procedure
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per-cutaneous
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What happens if a cyst is not palpable on physical exam?
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the FNA is typically performed under imaging guidance using fluroscopy, ultrasound, or computed tomography
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10021
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fine needle aspiration without imaging
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10022
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FNA with imaging
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T or F The parenthetical notes below the General subsection applies to both codes in the section
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True
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What do the notes under the General subsection tell you?
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To also report the code for the imaging if applicable such as fluoroscopic guidance
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Integumentary System Subsection
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What is included under the integumentary subsection?
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dermatological procedures, plastic surgery, and components of multiple surgical procedures (closure, flaps. and grafts)
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Integumentary procedures are often performed as ____ procedures
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staged
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Name some integumentary procedures
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-incision -biopsy -removing -paring/curettement shaving -destruction -excision -repair -adjacent tissue rearrangement -grafts -flaps
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Adjacent tissue transfer/rearrangement
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closure of defects by relocating a flap of adjacent normal, healthy tissue from a donor sire to an near by (adjacent) defect such as a traumatic skin wound or the site of excised lesion; a portion of the flap remains intact to provide blood supply to the grafted site
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Biopsy
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Removal and examination of tissue to establish a dx, confirm a dx, or determine the extent of a disease
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Flap
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Relocation of a mass of tissue (usually skin) that has been partially removed from one part of the body so that it retains its own blood supply
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Graft
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Any tissue or organ used for implantation or transplant
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Mohs microsurgery
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technique of excising skin tumors by removing tumor tissue layer by layer, examining the removed portion microscopically for malignant cells, and repeating the procedure until the entire tumor is removed
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Paring and curettement
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Removal of growths or other material from the wall of a cavity or another surface, a s with a curette; paring of lesions (e.g., corns and calluses) seldom, if ever, require local anesthesia.
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Shaving
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Horizontal slicing to remove epidermal and dermal lesions (e.g., without a full thickness dermal excision); removal includes scissoring or any sharp method
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Do not add _____ to skin, subcutaneous and accessory structures; nails pilonidal cyst; introduction; repair or destruction headings
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directional modifiers (lt and rt)
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The skin is not a ____ organ
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paired
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Skin, Subcutaneous and Accessory Structures
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What is included under the skin, subcutaneous and accessory structures headings?
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-I and D -Debridement -Paring or cutting -biopsy removal of skin tags -shaving of lesions -excisions of lesions
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Incision and Drainage
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I&D Section
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contains procedures that establish a drainage pathway for fluid that forms at sites of infection
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What does CPT I&D procedures include
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-cutaneous and subcutaneous drainage of cysts -fluid collections -infections -hematomas -pustules -seromas
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Do not report an I&D code if
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a procedure to excise a lesion results in drainage of an area either as part of the procedure or as a way to gain access to the lesion during the same op session
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Is it appropriate to report the I&D of a hematoma if it is performed during the same operative session as a excision,r repair, destruction, removal, and so on?
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NO
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CPT does not define type of excision in terms: simple, extensive, or complex. ______ is responsible for this
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provider
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There are different codes used if a cyst is over 2cm, is recurrent, or requires layered closure.
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True
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There is a different code used if plastic repair will be required in the future.
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True
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Extensive Cellulitis
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acute inflammation of skin's connective tissue that is caused by infection with bacteria
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What happens if simple I&D of a pilonidal cyst can not be performed because of extensive cellulitis?
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An antibiotic is prescribed and a code for complicated I&D of the pilonidal cyst is used. If the patient returns for an excision of the pilonidial cyst one week after the antibiotic surgery, then another code for the excision is also coded.
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T or F CPT describes procedures necessary to address complications
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True
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Complications are not reported with ______
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codes for the original surgery that resulted in the complication
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What happens if the original surgery procedure code is reported with procedure to treat the complication.
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NCCI will deny reimbursement for the procedure performed to treat the complication
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Lesion Removal
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Skin lesion
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pathological change in tissue
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What do you look at to accurately code a removal of a skin lesion?
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-method -status (benign or malignant) -size of the lesion -Site or body part lesion located -Type of wound closure/repair
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To calculate the size of a lesion refer to _________noted located in the CPT surgery
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excised diameter
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Excised diameter
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includes the size of the lesion plus its margins
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What should documentation of the excised diameter include?
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dimensions for the greatest size of the lesion as well as for the margin around the lesion
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When multiple lesions are removed, do not ______
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add together the greatest size of each separate lesions even when excised in one ellipse
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Margin
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the amount of surrounding tissue that must be removed to adequately excise the lesion
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The margin is calculated as the ______ from the lesion to the edge of the skin ellipse
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shortest distance
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An ellipse resembles an
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oval
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The _________ amount of tissue removed from the end of each ellipse is measured and uses to determine the excised diameter
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narrowest
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T or F When multiple lesions are excised using one ellipse, the narrowest margin between lesions is measured and used in addition to measurements of each end of the ellipse to calculate the diameter.
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T
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Benign lesions include
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-neoplasms -fibrous cysts -other inflammatory cystic lesions
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Malignant lesions include
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-melanoma -BCC -SCC
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Excised diameter includes the ____ plus its ____
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lesion plus its margins
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T or F Do NOT refer to the pathology report for the diameter because placing a lesion in formalin, the formaldehyde solution used to preserve organic specimens, can result in shrinkage.
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T
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Bulla
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Large Blister
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Large Blister
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same as vesicle onlly greater than 10 mm
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Vesicle
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Small Blister
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Small Blister
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Accumulation of fluid between the upper layers of the skin; elevated mass containing serous fluid; less than 10 mm
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Macule
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localized changes in the skin color of less than 1 cm in diameter
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Freckle is a
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macule
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2nd degree burn is a
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large blister
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herpes and chickenpox is a
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small blister
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Nodule
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solid and elevated; however, they extend deeper than papules into the dermis or subcutaneous tissues, greater than 10mm
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Cyst or wart is a
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nodule
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Papule
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solid, elevated lesion less than 1 cm in diameter
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Nevi is a
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papule
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Pustule
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vesicles or bllae that become filled with pus, usually described as less that 0.5cm in diameter
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Acne, furuncles,carbuncles, and impetigo are
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pustles
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Ulcer
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a depressed lesion of the epidermis and upper papillary layer of the dermis
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Stage 2 pressure ulser is a
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ulcer
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Tumor
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the same as nodule only greater than 2cm
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Basal Cell Carcinoma tumor is a
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tumor
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Urticaria
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Hives
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Hives
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localized edema in the epidermis causing irregular elevation that may be red or pale, may be itchy
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Insect bite and wheals are
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hives
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Lesions are measured in ____
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centimeters
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Just one type of ______ is reported for each lesion
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removal
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Types of removal
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-destruction -debridement -paring -currettement -shaving -excision
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Types of destruction
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-laser -freezing
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What do you do when multiple methods are used on a lesion removal?
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report only the destruction method
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What do you do when multiple distinct lesions are removed?
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report code for each lesion removed and attach modifier -59 to each code and be sure the provider has documented
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What does the biopsy of a lesion involve?
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the partial removal of a lesion usually performed at the same time as the removal of the entire lesion to obtain a pathological specimen
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When a lesion biopsy is performed as part of a removal then it is ______
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one procedure (report only the removal)
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Lesion removal may be require_____, ______ or _______ closure and a tissue transfer may be performed
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-simple -intermediate -complex
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T or F When the lesion removal requires bandaging, strip closing, or simple closure, the closure is included and not reported separately
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t
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Simple repair
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-one layer closure, non layer closure, single layer closure -involves the use of staples, sutures, and or tissue adhesives to repair superficial wounds involving epidermis, dermis, and or subcutaneous tissue
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Simple repair are _____ to a procedure
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integral
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Intermediate and complex repair when necessary are coded ________
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separately
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When a benign or malignant lesion is excised and complex closure is performed during the same op session, _______ is reported
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2 codes (excision and complex closure)
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When a scar is excised followed by complex closure, report ______ only
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the complex repair
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When multiple lesions are excised during the same op session, report a code for the excision of______
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each lesion
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When a malignant lesion is excised and the patient returns for further excision to ensure complete resection, report ______
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excision of malignant lesion even of no residual malignancy
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If a lesion has multiple sides, select _____ as the diameter
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the largest size
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When intermediate or complex repair is performed on multiple lesions, you should ________
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group according to site
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Nails
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...
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Most nail surgery is performed using ____ or ____
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local or digital block anesthetic
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Nail surgery is typically done on ________
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toe nails
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Nondystrophic nails
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normal nails with no abnormal development or changes due to aging, injury, or disease.
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Nail Debridement
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generally done to treat hypertrophic dystrophic nails and mycotic (fungal) nails
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How is nail debridement performed?
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mechanically bu using instruments such as a nail splitter, a nail elevator, and an electrical burr (sander)
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What must be done for lacerations to the nail bed where the wound extends under the proximal nail fold?
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a portion or all of the nail plate must be removed in order to visualize the laceration
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Report modifiers __ through ___ for procedures performed on a fingernail or toenail
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-FA through -F9
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Pilonidal Cyst
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...
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Pilonidal cyst defined
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contains a tuft of hair that developed as a result of repeated friction, which caused hairs to penetrate the skin occurring primarily in the sacro area
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Introduction
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Codes in the introduction heading include
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-tattooing -injection -insertion -removal -replacement (contraceptive capsules, tissue expanders, hormone implantation, non biodegradable drug implants, filling material such as collagen)
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T or F There are codes for intralesional injections for one or more lesions
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T
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The use of anesthesia is ______
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integral
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Do not report lesion injection codes with _______ codes unless separate lesions are injected with different agents
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intralesional chemo codes
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Attach modifier ___ to intralesional codes if multiple are performed during op session
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-59
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Defect
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wound that is the result of surgical intervention or trauma
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Donor site
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anatomic sire from which healthy skin is removed
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Primary Defect
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wound resulting from initial surgical intervention or trauma
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Recipient site
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anatomic site to which healthy skin is attached
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Secondary defect
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wound resulting from removal of tissue to create flaps or crafts
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Stroma
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Supporting tissue (matrix) of an organ
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Tissue approximation
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method of replacing sutures with material or substance which facilitates enhanced cosmetic results and faster healing of defects
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Undermining
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process of suing a surgical instrument to separate skin and mucosa from its underlying stroma so that the tissue can be stretched and moved to overlay a defect
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Repair (closure)
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...
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The repair section requires additional _____
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medical knowledge
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Simple< Intermediate, Complex Repairs
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...
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Simple
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superficial only simple one layer primary suturing required
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Intermediate
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One of the deeper layers of subcutaneous tissue and fascia are involved
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Complex
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Requiring more than one layered closure
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Single closure is coded as intermediate when
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the wound is heavily contaminated
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Layered does not always mean intermediate
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True
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Wound closures utilizing adhesive strips as the only repair material are reported with the appropriate _________
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E/M code
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Wounds are reported in _______
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centimeters
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Lengths of wounds should be _____
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added
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Modifier 51
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...
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Adhesive strips is a ______ code
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supply
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Coding Wound Repair
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...
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You should calculate the size of the wound in ___
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centi.
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______ together all the wounds and report one code for same site wounds
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add
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_____ should come first
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most complicated
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When a physician locates a foreign body and removes it then report _
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code for removal only
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Simple ligation of vessels is ___
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integral to wound repair
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Simple exploration is _____
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integral to repair
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Wound codes are based on ___
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lengths
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Code 13160 is a code for
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secondary closure because the first failed
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Wound repairs usually require _____
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local anesthesia
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Anesthesia is ______
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integral
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When closure can not be done through simple, intermediate, or complex then ________ or _________ is used
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-adjacent tissue transfer or rearrangement -Skin replacement
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Adjacent Tissue Transfer or Rearrangement
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...
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To calculate adjacent tissue transfer size
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combine the defect area with the defect area created by tissue transfer (in centimeters)
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When a procedure is done to repair a secondary defect then
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report an additional code
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Advancement flap
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movement of tissue in straight line from donor to defect site using a sliding process, once movement is achieved, the flap is sutured in place; advancement flaps are not rotated or moved sideways
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Double Pedicle Flap
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Maintains blood supply from both ends of the flap incision made to create a curvillnear flap contiguous with the defect; flap is pivoted and sutured in place over the defect
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Free Flap
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Island flap that is detached from donor site and reattached at recipient site via micro-vascular anastomasis
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Islamd Flap
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Flap consisting of skin and subcutaneous tissue with a pedicle comprised only of nutrient vessels; also called island pedicle flap
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Myococutaneous flap
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autologous graft consisting of both skin and muscle tissue from the donor site
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Random pattern flap
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Mycocutaneous flap with random pattern of arteries
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Rhomboid flap
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Random pattern flap that can be raised on any or all corners of a parallelogram configuration, typically 120 and 60 degrees; also called a limberg flap
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Rotation flap
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Incision made to create a curvillinear flap contagious with the defect; flap is dissected, freed. pivoted, and sutured in place over the defect
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Tissue Management
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Defined by anatomic site and size of defect; includes excision of the defect of lesion; terms used to describe transfer or rearrangement include Z-pasty, W-plasty, V-Y-plasty, rotation flap, advancement flap, and double pedicle flap
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V-Y Plasty
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After creation of a V-shaped incision, the edges of the incision are drawn together and sutured, converting the incision to a Y shape
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W-plasty
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Both edges of the wound or defect are trimmed into the shape of a W or multiple Ws
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Z-Plasty
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Involves making an incision along with two additional incisions, one above and another below, creating a z formation
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Skin replacement surgery and skin substitutes, Flaps, and other flaps and grafts
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...
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autograph
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Xplantation of tissue from same individ.
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Tissue cultured autografts
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supplied by labs
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What modifier should be used with tissue cultured autografts
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58
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Why use modifier 58 with tissue cultured autographs
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Bc labs can grow a limited amount of tissue so they are staged procedures
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Acellular dermal replacement
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Bioengineered artificial skin
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Allograft
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Xplantation of tissue from someone of the same species
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xenograft
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Xplant from a different species (pig, cow, etc)
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2 types of skin grafts
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Free skin graft Pedicle graft
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2 classifications of free skin grafts
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Full thickness Split thickness
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Free skin grafts
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Completely separated from donor site
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Full thickness skin graft
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Includes epidermis and dermis
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Split thickness skin graft
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Entire epidermis and portion of dermis
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Where are full thickness skin grafts oftern harvested?
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From inguinal folds, supraclavicular region, abdomen, thigh, and postauricular skin bc of the availability of excess skin in those regions
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When are split thickness grafts used?
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To repair edematous, infected, or large wounds (such as burns)
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Before coding a skin graft the area over the graft should be free of infection or other disease, if it requires the recipient area to be cleansed what should also be reported with the skin graft code?
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A surgical preparation code
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Do codes include simple debridement when coding grafts?
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Yes for the recipient area only, if the donor site requires debridement it must be coded additionally
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Example: If a patient needed a graft for the nose and this was accomplished by using the cheek; however, the cheek needed to be repaired as well and this was done using the thigh. What is the donor site you would code?
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The cheek bc it was a donor site that required a graft for repair
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Pedicle skin grafts
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Not immediately separated from donor site, a portion is xferred to the recipient site and the remaining portion (base) is attached to the donor site so that there is a vasculature and nerve supple to recipient area. After the recipient area's blood flow is good the base is then grafted.
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What is the delay technique
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Used to improve blood supply to the base of a flap, by temp. obstructing blood supply to the flap to allow a relatively long flap to be xferred onto a narrow pedicle
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When you assign skin grafts what should you identify
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1. Type of graft 2. Recipient site 3. Surface area of recipient site by cm.
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t/f only one type of skin graft is usually applied to an anatomical locationt/f only one type of skin graft is usually applied to an anatomical location
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true
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if multiple anatomic locations require different grafts what modifier should you use
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59 to reported as a different site
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If a benign/malignant lesion is excised and the surgical prep and free skin graft are performed how many codes should be reported?
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2 (one for the excision of the lesion and another for the graft)
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How many codes are reported if a lesion is excised with a flap closure?
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1 just the flap closure
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t/f generally, debridement of nonintact skin in anticipation of a skin graft is necessary prior to the application of the skin graft and is included in the skin graft?
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true
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If skin is intact when is the graft performed?
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After excisional prep of intact skin, so an excisional preparation are separately reported.
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If multiple tissue rearrangements and skin grafts procedures are required during the same operative session you must make sure you _______
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Report each one separately and do not add together the total sq. cm for repair of different defects
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An adjacent tissue xfer or rearrangement requires hwo many codes
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1
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How many codes required for a free skin graft?
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2 or more (graft, surgical prep, repair of donor site if needed)
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How many codes needed for a flap (skin and or deep tissue)
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1 or more (flap and repair of donor site if needed)
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Other flaps and grafts require how many codes?
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1 or more (flap/graft and the repair of site)
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Dermabrasion
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Performed for conditions such as acne scarring, wrinkles, rhytids, and keratosis. Uses a rotary devise to sand down the raised lesions or thick skin
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-What codes should be used for tattoo removal? Why
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15780-15782 bc tattoo removal usually involves the dermis
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Is microdermabrasion classified in cpt
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No, which means unlisted code 17999 is used
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Microdermabrasion
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Skin freshening technique used to repair facial skin that is damaged by the sun or aging. Uses a sandblaster device used to spray tiny crystals across the face
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chemical peel
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Involves the use of chemical agents to remove wrinkles and abnorm. Pigmentation
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Actinic keratosis (AK)
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Common sun induced lesion of the epidermis with potential to become skin cancer.
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AK is usually treated by what procedures
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Cryosurgery with liquid nitrogen, topical drugs, and curettage.
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Blepharoplasty
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Any surgical repair of the eyelid
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What does a blepharoplatry do?
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Remove the orbicularis muscle, orbital fat, and excess eyelid around the orbit
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What is a blepharoptosis repair?
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Performed on the levator muscle of the eyelid
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Should you use a modifier with a blepharoplasty code?
answer
Yes, to indicate which eyelid
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Rhytidectomy
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Excising a section of the skin to eliminate wrinkles and can be done to reduce glabellar frown lines
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Glabellar frown lines
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Vertical furrows in the forehead and btw the eyebrows
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Graft procedures for facial nerve paralysis involves what
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The removal of connective tissue from the body, the graft is then xplanted to the face to reanimate previously paralyzed areas
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Abdominal panniculectomy aka
answer
Abdominoplasty
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What is an abdominoplasty
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Performed to remove fatty tissue and excess skin from the lower to middle portions of the abdomen
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When is an abdominoplasty normally performed
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On individs who have lost considerable weight
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lipectomy
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Removal of localized subcut fat deposits by suction curettage or blunt cannulization
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When a physician does a suction-assited lipectomy what is done
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A liposuction cannula is inserted through the fat to remove excess deposits
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Is it appropriate to report a separate code for each area of liposuction to the trunk?
answer
yes
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Pressure Ulcers (Decubitus Ulcers)
answer
...
question
Pressure ulcer aka
answer
1. Decubitus ulcer 2. Bedsore
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Pressure ulcer
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Ulceration of the skin and underlying tissue
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Pressure ulcers result in
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Inflammation, swelling, necrosis, ulceration, and infection
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Does the primary excisional procedure of a staged process include the flap/graft procedures?
answer
No they are reported separately
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If a muscle or myocutaneous flap is planned for a subsequent session prospectively what should be reported
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The appropriate flap code and modifier 58
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Burns, Local Tx
answer
...
question
Is the application of material such as biobrane included in burn txs?
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yes
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What should be identified when coding burn txs
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1. Percent of body surface 2. Severity of burn
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What is the severity of burn classified into
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1. Partial thickness (first and second degree) 2. Full thickness (third degree)
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What do you use to determine the extent of body surface involved in the burn
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The rules of nine
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Rules of nine
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Divides the body into 9 segments by percentage, this differs by the patients age
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Rules of Nine
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1. Head = 4 ½ 2. Arms 4 ½ ea 3. Legs 9 ea 4. Trunk 18 5. Genital 1
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Destruction
answer
...
question
Destruction
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The ablation of tissue by any method
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Should you report a separate code for debridement when the intended procedure is performed during the same session as the debridement?
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No, its integral
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Destruction of benign or premalignant lesions and destruction of malignant lesions, any method
answer
...
question
Each lesion treated is report as
answer
a separate code
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Mohs micrographic surgery
answer
...
question
What is mohs micrographic surgery
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An advanced tx proceure used to treat basal cell carinome and squamous cell carcinoma skin cancers
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Dermatologists trained in mohs surgery serve as ___, ___, and ___
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Surgeon, pathologist, and reconstructive surgeon
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How is mohs surgery performed?
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By using a microscope to trace and ensure the removal of skin cancer to its root
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t/f reporting both mohs surgery codes and surgical pathology codes together is inappropriate
answer
true
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if a mohs surgeon performs a diagnostic biopsy to make sure the decision to perform the procedure is appropriate what codes are reported?
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The biopsy code is reported separately with a modifier 58
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breast
answer
...
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What may be used to detect breast cancer
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1. Mammo 2. Ultrasound 3. Mri 4. Fna 5. Core biopsy 6. Surgical biopsy
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What tx plans may be used to treat breast cancer
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1. Mastectomy 2. Radiation 3. Breast reconstruction 4. Etc
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What may not be reported separately at the time of a lesion excision of the breast when there is an ESTABLISHED dx
answer
Fna biopsies, core biopsies, open incision/excision biopsies, and related procedure (unless performed on a different lesion or on the other breast)
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If there is not an established dx and the decision to perform surgery is dependent on the biopsy, can the biopsy code be reported separately
answer
Yes, with modifier 58
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Breast biopsies are performed in what 3 ways
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1. Fine needle aspiration 2. Needle core 3. Open
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Needle core biopsy is classified in what 2 ways
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1. Hand operated 2. Sterotactic localization
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What 2 ways is open biopsy classified
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1. Excisional 2. Incisional
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Fine needle aspiration
answer
...
question
Fna of the breast is reported depending on ______
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Whether imaging guidance was used during the procedure
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Describe an fna
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Uses a thin needle to insert through the mass several times. Suction is applied as the needle is withdrawn to obtain stands of single cells from ctologic dx
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If an fna is performed using imaging guidance or sterotactic localization what other code should be reported
answer
77031
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Needle core biopsy
answer
...
question
Describe needle core biopsy
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After tissue is obtained it is fixed for routine pathologic section
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Sterotactic localization
answer
Indicated for nonpalpable lesions bc it uses specialized 3d imaging to target the lesion
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What is used to obtain a needle core biopsy
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The breast is placed in fixed position and a biopsy gun is used
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Should you use an additional code with a needle core biopsy
answer
Yes, such as one for sterotactic localization or mammo guidance
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t/f a biopsy code is assigned for each biopsied site when done by needle core?
answer
True, example if 3 needle core biopsies sites are performed then you will have 3 codes
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Open biopsy
answer
...
question
Open biopsy
answer
Incision/excisional depending on the amount of the lesion removed'
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Excisional biopsy
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Removes the lump or suspicious area in it entirety
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Incisional biopsy
answer
Removes a portion of the lesion by slicing into it and is usually performed on large tumors
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What does excisional breast surgery include
answer
1. Certain biopsy procedures (precut or open) 2. Removal of cysts or other lesions 3. Surgical tx of the breast and chest wall malignancies
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An excisional biopsy is not a ______
answer
Lumpectomy
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What is a lumpectomy
answer
A partial mastectomy
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Should you report modifiers indicating which breast when a breast procedure is performed?
answer
yes
question
When more than one lumpectomy is performed in different areas of the breast what modifier should be used
answer
51
question
mastectomy
answer
...
question
What does partial mastectomy procedures describe
answer
Open excisions of breast tissue with specific attention to adequate surgical margins.
question
partial mastectomy
answer
Making an incision the skin and fascia over the breast tumor and clamping lymphatic and blood vessels, then excision of the tumor mass along with a section of the breast tissue is done
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Partial mastectomy aka
answer
1. Lumpectomy 2. Quadrant ectomy 3. Segmental mastectomy 4. Tylectomy
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Total mastectomy procedures include
answer
Complete mastectomy, modified radical mastectomy, simple mastectomy, and subcut mastectomy
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Define total mastectomy
answer
Surgical removal of the entire breast, including the pectoral fascia and a sampling of axillary lymph nodes
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Define radical mastectomy
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Total mastectomy that includes removal of the breast and nipple, pectoral muscles, axillary lymph nodes, and internal mammy lymph nodes
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Define modified radical mastectomy
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Total mastectomy that includes removal of the breast and nipple, axillary lymph nodes, and pectoral minor muscle
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Breast repair and reconstruction
answer
...
question
What elements are included in the breast reconstruction codes
answer
1. Elevation and xfer of the flap 2. Closure of the donor site 3. Breast contouring 4. Insertion of breast implant or prosthesis, when performed
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Breast reconstruction with TRAM flap refers to
answer
A single pedicle that includes closure of the donor site
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Tram
answer
Transverse rectus abdominis myocutaneous flap
question
Tram flaps include what
answer
1. Creation of breast pocket 2. Elevation of ab flap 3. Muscle dissection 4. Flap xfer 5. Fascial closure (donor site) 6. Ab closure 7. Breast contouring
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Are the excisions of lesions during the same op session as a mastectomy reported separately
answer
No, unless performed to est. the malignat dx before proceeding to the mastectomy (use modifier 58 if this happens)
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What other types of codes are generally integral with mastectomy codes
answer
1. Other integumentary codes for incision and closure 2. Biopsy lymph nodes 3. Removal of muscle tissue 4. Ipsilateral lymph node dissection
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If a breast lesion is identified and treated and medical necessity indicates that biopsy of the other breast is needed can you report a separate code
answer
Yes, be sure to use a modifier to indicate which breast
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t/f breast reconstruction codes also include the insertion of a prosthetic implant and they are not reported with cpt code that describe the insertion of breast prosthesis only
answer
true
question
if breast procedures are performed on both breast what modifier should be used
answer
50